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The Earl of Strafford: My Lords, I congratulate the noble Lord, Lord Perry of Walton, and his committee on their landmark report and conclusions, which are both humane and pragmatic. Because of its illegal status, few chemical trials have been done on the medical use of cannabis, but there is a wealth of anecdotal evidence. Anyone who doubts that should read Marijuana--the Forbidden Medicine by Grinspoon and Bakalar, which makes compelling reading and charts the medical use of cannabis from its earliest mention, not on an Assyrian tablet but in a Chinese herbal 5,000 years ago, to its present-day use. Of special significance is the store placed on cannabis by the Victorians when it was introduced into modern western medicine in the mid-19th century. Between 1840 and 1900, more than 100 papers were written recording its therapeutic uses.

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The heart of that book is an anthology of case histories of people suffering from severe or terminal illness who found that cannabis was the only substance that really helped. They were suffering from a variety of chronic conditions and there was a pattern of trying recommended drugs that did not work or, even if they did, produced unpleasant side effects. They turned to cannabis only as a last resort--sometimes with great reluctance and seldom with any expectations of improvement. Clearly their lives were transformed. Their physical and mental state improved and the quality of their lives was enhanced. Sometimes, it saved their lives.

The cumulative weight of evidence from those personal testimonies is compelling but all anecdotal--and here is the rub. Anecdotal evidence is considered substandard and is disallowed because it is not scientific. The phrase "anecdotal evidence" means personal experience and in this context it cannot be brushed aside. It is too extensive and authentic. Each case says, "Cannabis works for me". It can be argued that a good case history provides the smallest research study of all.

A classic example and an especially illuminating account of how one multiple sclerosis sufferer's life was transformed by cannabis is given by Clare Hodges to the Select Committee, as mentioned by the noble Lord, Lord Rea. As the Director of the Alliance for Cannabis Therapeutics, her organisation has received 200 letters from MS sufferers, giving detailed accounts of the benefits that they gain from its use. She also received 50 letters from people with spinal injuries and 20 with epilepsy, depression, arthritis, AIDS or cancer. Only five people responded who had either gained no benefit or suffered unwanted side effects.

Last year's BMA report, The Therapeutic Uses of Cannabis, was significant and reflected the frustration felt by a growing number of doctors because they could not prescribe cannabis to patients who might benefit, who were forced to break the law to obtain it. What has to be questioned is the BMA statement that,

    "the information is meagre, but nevertheless it can be concluded that cannabis is unsuitable for medical use".
Those who use it often in preference to the few cannabinoids available would disagree, and that point was commented on by Dr. Notcutt, with his work on nabilone, and by Clare Hodges. Using crude cannabis may not be ideal, but it works.

Eventually, the exact cannabinoids or combination of them that do benefit people will be unravelled, but that is at least five years away. Meanwhile, people who use cannabis remain criminals and often face a stark choice. A good example is the man crippled by rheumatoid arthritis who was registered as 97 on the arthritis severity scale. That rating dropped to seven after using cannabis. He said:

    "My problem is that I don't want to flout the law deliberately. What can I do? Get better and break the law or feel worse?".

The committee's recommendation that cannabis should be transferred from Schedule 1 to Schedule 2 and that doctors should be able to prescribe it to named patients, as they can morphine or amphetamine, would

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give immediate help to people who need it and would make further research less complicated. That is also in line with public opinion. Polls have shown a clear majority in favour of medical legislation. That was highlighted a fortnight ago when AOL, the Internet service provider, organised an on-line survey asking, "Should cannabis be legalised to ease serious and terminal illness?". The result was a resounding 81 per cent. in favour and 19 per cent. against.

This issue is summed up for me by a letter written to the Independent on Sunday, which stated,

    "I have multiple sclerosis and use cannabis to relieve unpleasant muscle spasms. It makes me very angry that I have to become a criminal to obtain and take this safe, cheap and very effective drug. Where is the sense?".
I believe that the Government should take notice of these views and have the courage to implement the committee's recommendations.

9.55 p.m.

Lord Clement-Jones: My Lords, this has been an extremely interesting debate. I particularly wish to thank my noble friend Lord Perry of Walton and his colleagues on the committee for a report that we on these Benches consider shows enormous humanity and good sense. As we have heard tonight from many members of the committee, the report examines with enormous care the evidence and the arguments for the medical use of cannabis.

As regards the medical benefits, the committee makes no bones about the fact that cannabis has quite a number of adverse effects. The committee has admitted that it has relied on anecdotal evidence. It seems clear that there is potentially a major role for cannabis to play in the care and treatment of MS sufferers, and that there may be other important uses--for example, the relief of pain of terminally ill patients, and for those undergoing chemotherapy.

As my noble friend Lord Perry of Walton made clear, the report concludes unanimously that, having balanced the risks with the benefits, the case is made out for clinical trials to be carried out with cannabis and its derivatives and analogues such as THC and nabinol, as the BMA suggested in its 1996 report. As we have heard, the report also--this is more controversial--concludes that cannabis should be moved from schedule 1 to schedule 2 of the dangerous drugs regulations. That would allow GPs to prescribe cannabis at their own risk for those such as MS sufferers who find it beneficial. In itself this recommendation goes further than the BMA was prepared to go in its evidence and in its original report, or indeed, subsequently in its response to the committee's report.

I say at once that I and my health spokesmen colleagues in the Commons back the committee's recommendations. I am particularly fortified in that view by the fact that one of our number, Dr. Peter Brand, MP, is a GP of many years' experience. He certainly believes that it is practicable to implement the recommendations of the committee. I am heartened also by the support of practitioners in this House--for example, the noble Lords, Lord Winston and Lord Rea--who also take that view.

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The argument used by those who wish simply to wait for the results of clinical trials is, in my view, inhumane. They argue in summary that there are more than 60 cannabinoids in cannabis and it would be dangerous to allow cannabis to be prescribed until we know precisely which elements of cannabis cause the beneficial effects. The noble Lord, Lord Dixon-Smith, made an analogy with the lottery which I thought was particularly apposite. The fact is that such trials could take five years and more to identify those elements if one had to try all the different combinations.

There have been few trials to date, as we have heard. We have also heard about trials that are now in prospect. But shall we really see an upsurge of interest by the pharmaceutical companies when cannabis will still have the stigma of Schedule 1 status attached to it? Should we leave multiple sclerosis sufferers and others deprived for this period at a vital time of their lives, or do we in effect force them to become criminals? It is a cliche to say it, but it is nevertheless true that we all have only one life. Do we not have a duty to ensure that patients have as little suffering as possible? Are we really saying, after all this time, that we know so little about cannabis that we cannot risk terminal patients taking it rather than morphine, which we know is far more potent and addictive?

Pain management was a new science when my late wife was in terminal care 10 years ago. Now it is much more sophisticated. Do we think that palliative and terminal care doctors and nurses would behave irresponsibly? Would MS sufferers abuse the system? Is it not better that they should just simply have to produce a prescription if prosecuted rather than having to be taken to court and have the indignity of making a plea of mitigation? I do not accept what the noble Lord, Lord Mackenzie of Framwellgate, said. Why does he simply assume that because doctors may be prescribing cannabis for smoking, there will be abuse of the system?

I found the last paragraph of the evidence of the Multiple Sclerosis Society particularly poignant:

    "The ... Society does not encourage people with MS to break the law. We do however understand why some people who face intolerable symptoms have chosen to make their own decision about cannabis use, recognising the implications of their choice. Where the medical evidence warrants it, we hope that the police and the courts would deal with such people in an appropriately compassionate fashion".
I do not believe that such a situation would be at all humane for MS sufferers. After all, what we are asking them to do is to throw themselves on the mercy of the courts.

We have heard that cannabis is not new on the medicinal scene. We believe that Queen Victoria used it, as my noble friend Lord Perry of Walton mentioned.

My Commons colleagues and I are particularly disappointed by the immediate negative response of the Minister Mr. Howarth, who with indecent haste indicated disagreement with the committee's report. Ministers should be quite clear about the precise recommendations of the committee. It is not saying that doctors should immediately be able to prescribe, but it

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is saying that consultations--as is proper--should first take place with the Advisory Council on the Misuse of Drugs.

The committee also very clearly states that the medical profession should provide clear guidance on the prescription of cannabis. This would deal with aspects such as those suffering from schizophrenia. That is the sensible way forward, but it is not that being taken by the Government.

I believe that the Government's decision is less of a medical than a political decision. Medical considerations have become tangled up in the Government's mind with the recreational aspects which the committee was scrupulous in not getting confused. The Government appear to be terrified of appearing to be soft on drugs. They appear to be terrified of an adverse headline in the Daily Mail. As a result of the Government seeing the issue purely as one of law and order, a great many patients who could have benefited from cannabis to relieve their condition will suffer.

As regards the wider agenda and the recreational use of drugs, I note the committee's final conclusions. However, my party has strongly advocated for some years now the setting up of a Royal Commission which would provide a thoroughgoing investigation into the effects of drug use and misuse generally in this country. Such a Royal Commission could also examine the best ways in which to tackle the problem at its roots.

My party believes that that is the sensible way of dealing with the recreational aspects, which are entirely separate from the medical aspects. On the medical front, I very much hope that the Government will change their collective mind. Even if I had not been persuaded before this debate, I would be doubly persuaded now.

10.3 p.m.

Lord McColl of Dulwich: My Lords, I too add my thanks to the noble Lord, Lord Perry of Walton, for presenting the report and for all the valuable work involved.

As a member of the medical profession for the past 40 years, I have always taken a particular interest in the care of those who are dying. In the past 13 years, I have been intimately involved in the Mildmay Mission Hospital, which was the first hospice in Europe devoted to the care of men, women and children dying of AIDS.

I have never had any problem in seeing my task as relieving distress, whether that distress was pain, nausea, respiratory distress, anxiety, depression or whatever. Nowadays that is a much more precise practice as we have a host of different drugs to deal specifically with each symptom, rather than showering them with crude compounds containing scores of different chemicals of unknown quantity and unknown effects.

With chronic incurable diseases of all kinds, the search continues for more precise drugs which can deal with a variety of symptoms. But the medical use of cannabis in Europe and North America has declined this century, first, because there is no standardised preparation of cannabis and, secondly, because of its unreliable absorption when taken by mouth.

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Cannabis has a very complex structure and even for a given strength produces irregular, widely varying, and thus unreliable, results. That is why it was ejected from the British Pharmacopoeia in 1932; its dismissal was in no way related to its legal status on the street, its so-called recreational use.

We support the committee's view that evidence-based findings fully justified the rejection of the recreational use of cannabis and that its present controlled status should be maintained. We also fully support the committee's recommendation that there is a great need for scientifically rigorous trials, and that the notion of smokable medicines should continue to be rejected.

In referring to the smoking of cannabis, the noble Lord, Lord Perry of Walton, might have emphasised that smoking cannabis is even more dangerous than smoking ordinary cigarettes because it contains a greater concentration of cancer producing substances. It results in a five-fold greater increase in carboxyhaemoglobin concentration, which makes that haemoglobin molecule less available to carry ordinary oxygen, and that places an additional burden on the heart; and, as the noble Lord, Lord Mackenzie of Framwellgate, mentioned, a three-fold greater increase in the amount of tar inhaled. Also, it leads to retention in the respiratory tract of one-third more tar than the smoking of ordinary cigarettes.

Controlled clinical trials are difficult when one is comparing the smoking of cannabis with something else. It is difficult to find a suitable placebo.

One of the cannabinoids, nabilone, was licensed as a drug to help control the nausea and vomiting produced by chemotherapy in cancer patients. Apparently it is not much used for that purpose because it is not nearly so good as the new and more powerful anti-nausea drugs such as ondansetron and others with names that are difficult to pronounce. The other advantage of these compounds is that they can be given intravenously, which is useful for patients who are vomiting.

The committee has argued that it "received enough anecdotal evidence" to convince it of the medical value of cannabis, although it concedes that "there is not enough rigorous scientific evidence". The committee says its "principal reason is compassionate". I am not sure that it is really compassionate to expose sick people to unproven drugs with psychoactive side effects; there are approved protocols for the introduction of drugs, and even then mistakes are made and problems arise. The only people likely to benefit would be the legal profession, advancing claims for damage by this improperly approved compound.

When we examine the anecdotal evidence, it consists largely of people who have smoked cannabis saying that they prefer smoking it to having it in other forms. First, I think we should remind ourselves that the word "anecdote" means in Greek "not published", which is arguably what most anecdotes should remain. Secondly, I remember well patients telling me in the 1950s that they much preferred digitalis leaf to the new-fangled preparation digoxin. They said that the leaf, which we prescribed in grains, as I think my former tutor, my noble friend Lord Butterfield, will confirm, was much

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more effective than the pure digoxin. The truth of the matter is that the amount of pure digoxin in each digitalis leaf varied a great deal. In fact, it is thoroughly bad medicine to use that preparation.

I work on the principle that the customer is always right, but sometimes he is not right, and in this case he is quite wrong. After all, only 1 per cent. of people suffering from multiple sclerosis are believed to use cannabis, so it cannot be described as a "widespread experience". Further anecdotal evidence is that cannabinoids are not as good as crude cannabis because they do not make the patient "high".

It is the job of the Opposition to oppose the Government over policies that it thinks are wrong but to support them over policies it thinks are right. We on these Benches agree with the Government that cannabis should not be rescheduled to allow doctors to prescribe it until the safety, quality and efficacy of a medicinal form have been established by rigorous scientific means and until the Medicines Control Agency issues a marketing authorisation.

We fully support the stand taken by the British Medical Association. I think it is worth saying that the BMA today is more helpful and constructive than I have ever known it. The BMA summarises this situation well when it says:

    "Cannabis contains over 400 chemical compounds including more than 60 cannabinoids, with considerable variation in the concentration present in different preparations".
Even if cannabis were shown to have therapeutic benefits, it would not be possible to know which particular agents were beneficial and medical knowledge would not be advanced or treatment improved. For those reasons, as well as because of the known toxic constituents in cannabis smoke, the BMA consider that cannabis is unsuitable for medical use. They say that such use should be confined to known doses of pure or synthetic cannabinoids. We agree with that.

I should like to emphasise a point made by the Under-Secretary of State at the Home Office in January 1997 when he said that many of those calling for the medical use of cannabis are using it as a stalking horse to promote the campaign for its legalisation. The noble Lord, Lord Mackenzie, mentioned that point.

Paul Boateng, the Health Minister, said that we should not accept a lesser standard of evidence in the case of cannabis because of pressures on behalf of people who are convinced of its therapeutic value.

It is worth stating that in the United States organised campaigns to legalise cannabis have usually started by launching a debate on its medical uses. There are, of course, many sincere people who advocate the use of cannabis for medical purposes and whose only concern is to alleviate suffering. But many believe that the efforts of these sincere people are being cynically deployed by other groups seeking legislation. These groups are well aware of the propaganda value in gaining ground in the medical cannabis debate.

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Another disadvantage of legalising the use of cannabis for medical reasons is that the United Kingdom would then find itself out of step with many other countries. In this field I do not think we should be pioneering in that way.

In conclusion, I again thank the committee for this valuable report which has highlighted the difficulties of the subject. I very much hope that the Government will support the plea of the committee for more rigorous and scientific research in this field.

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